Director, Standards Development and Interpretation

Joint Commission•Oakbrook Terrace, IL

About The Position

The Director, Standards Development and Interpretation is accountable for overseeing the development and implementation of accreditation and certification programs in alignment with the Joint Commission’s mission and vision. The primary focus of accreditation in the Ambulatory, Critical Access and Acute Care Hospital accreditation programs and all certification programs within Joint Commission enterprise. Key areas of responsibility include standards development, survey methodology formulation, standards interpretation, post-survey report processing, and completion of evidence of standards compliance. Reporting to the Vice President, Accreditation/Certification Program Development and Accreditation Management, the Director oversees the end-to-end accreditation decision-making process to ensure compliance with regulatory and accreditation standards to include: Standards Development, Standards Interpretation and Guidance, Accreditation/Certification Decision oversight, Internal and External Stakeholder collaboration and ongoing quality improvement in accreditation and certification programs. Additionally, initiates strategies to ensure the delivery of high-quality accreditation and certification offerings and maintains an awareness of evolving healthcare trends affecting accredited or certified organizations. The Director manages teams responsible for creating and interpreting standards within accreditation and certification programs.

Requirements

Master’s degree or equivalent in healthcare administration or a medical/health care-related discipline.
Ten or more years of experience in healthcare including prior leadership experience.
An exceptional ability to communicate the mission of the Joint Commission and to promote the Joint Commission’s leadership in assessing and improving the quality of health care
Demonstrated customer service skills.
Interpersonal skills to interact effectively with individuals at various levels both inside and outside of the organization, sometimes in sensitive situations.
Demonstrated presentation and analytical skills.
Demonstrated ability to function well in a fast-paced, highly stressed and visible environment.
Strong computer skills preferred, including familiarity with databases, graphics, and word processing.
Must be able to lift 25 pounds
Must be able to climb stairs and ladders.
Must be able to travel up to 20% of work time on short notice.

Responsibilities

Collaborates with department leadership to develop and implement policies, procedures, and workflows designed to ensure efficient production of high-quality work.
Coordinates with other departments across the Enterprise to confirm that standards creation, interpretation, and survey methodologies meet all applicable regulatory requirements and contribute to quality and safety improvements.
Provides information on the development, intent, applicability, and survey of standards in response to inquiries from surveyors, health care organizations, consumers, government representatives, and other individuals within and outside Joint Commission and within specified turnaround times.
Oversees the organization and dissemination of standards interpretation position statements and answers to Frequently Asked Questions (FAQs).
Oversees maintenance of the Consistent Interpretation Technology (CITe) database.
Evaluates onsite survey issues of escalating risk & potential Immediate Threats. This may occur during normal business hours or during evening hours to accommodate JC surveyors.
Serves as faculty for new surveyor education, continuing surveyor education and development, in-service education of central office staff, and select other education programs, both on-site and nationwide.
Provides support to the Office of Quality & Patient Safety through the review of complaints and CMS reports relating to accredited organizations upon request.
Participates in the development and review of articles for various publications and participates in the development or evaluation of educational and resource materials as requested by the Department of Publications and JCR.
Ensures timely completion of work products in accordance with departmental and enterprise policies and procedures.
Oversees planning, execution, and assessment of departmental activities and projects managed by staff, effectively allocating resources (both personnel and budget) in response to evolving priorities.
Participates in special projects or task forces as assigned.
Manages assigned teams, including responsibilities for interviewing, hiring, and administering corrective actions as needed, in alignment with Joint Commission policies and procedures.
Represents the Joint Commission, its division, and department in both internal and external engagements such as presentations and national forums.
Participates in and implements quality assurance initiatives to promote consistency and accuracy in work products.
Manages Senior Associate Directors in respective programs.
Leads and/or participate in special projects or task forces as assigned.